REVIEW

Circumcision Rates in the United States: Risingor Falling? What Effect Might the NewAffirmative Pediatric Policy Statement Have?

Brian J. Morris, DSc, PhD; Stefan A. Bailis, PsyD; and Thomas E. Wiswell, MD

Abstract

The objective of this review was to assess the trend in the US male circumcision rate and the impact thatthe affirmative 2012 American Academy of Pediatrics policy statement might have on neonatal circum-cision practice. We searched PubMed for the term circumcision to retrieve relevant articles. This review wasprompted by a recent report by the Centers for Disease Control and Prevention that found a slight in-crease, from 79% to 81%, in the prevalence of circumcision in males aged 14 to 59 years during the pastdecade. There were racial and ethnic disparities, with prevalence rising to 91% in white, 76% in black, and44% in Hispanic males. Because data on neonatal circumcision are equivocal, we undertook a criticalanalysis of hospital discharge data. After correction for underreporting, we found that the percentage haddeclined from 83% in the 1960s to 77% by 2010. A risk-benefit analysis of conditions that neonatalcircumcision protects against revealed that benefits exceed risks by at least 100 to 1 and that over theirlifetime, half of uncircumcised males will require treatment for a medical condition associated withretention of the foreskin. Other analyses show that neonatal male circumcision is cost-effective for diseaseprevention. The benefits of circumcision begin in the neonatal period by protection against infections thatcan damage the pediatric kidney. Given the substantial risk of adverse conditions and disease, some arguethat failure to circumcise a baby boy may be unethical because it diminishes his right to good health. Thereis no long-term adverse effect of neonatal circumcision on sexual function or pleasure. The affirmative2012 American Academy of Pediatrics policy supports parental education about, access to, and insuranceand Medicaid coverage for elective infant circumcision. As with vaccination, circumcision of newborn boysshould be part of public health policies. Campaigns should prioritize population subgroups with lowercircumcision prevalence and a higher burden of diseases that can be ameliorated by circumcision.

ª 2014 Mayo Foundation for Medical Education and Research n Mayo Clin Proc. 2014;89(5):677-686

From the School of Med-ical Sciences, University ofSydney, Sydney, NSW,Australia (B.J.M.); PeopleIncorporated, St Paul, MN(S.A.B.); and Center forNeonatal Care, Orlando,FL (T.E.W.).

T he present article examines the trendin male circumcision in the UnitedStates, contemporary issues, and what

these might mean for the future of circumcisionpractice in this country. The publications refer-enced were selected for relevance from amongthe first author’s (B.J.M.) collection of more than3000 on the topic of male circumcision that hadbeen retrieved using the search term circumcisionfrom weekly PubMed alerts between January1999andDecember2013and fromCurrentCon-tents between January 1988 andDecember 1998.All the articles were filed under the subcategoriesof rates, policy, ethics, risks, and each of themed-ical conditions that male circumcision affects.

WHAT THE LATEST RATES DATA SHOWThe review was triggered by a recent report bythe Centers for Disease Control and Prevention

Mayo Clin Proc. n May 2014;89(5):677-686 n http://dx.doi.org/10.10www.mayoclinicproceedings.org n ª 2014 Mayo Foundation for M

(CDC) on the prevalence of circumcision amongmales aged 14 to 59 years in the United States.1

The CDC data were obtained from the NationalHealth and Nutrition Examination Surveys(NHANESs) for 2005 to 2010, in which in-terviews were administered to a nationally re-presentative sample of 6294 males. The CDCresearchers estimated total circumcision preva-lence to be 80.5% (Table 1). Racial differenceswere apparent: Prevalence was 90.8% in non-Hispanic white, 75.7% in non-Hispanic black,and 44.0% in Mexican American males. Therecent figures are higher than in the CDC’s previ-ous report based on NHANES data for 1999 to20042 (Table 1).

Because these data are formales aged 14 to 59yearsdand most circumcisions in the UnitedStates take place during the neonatal perioddthey largely reflect past practice. What happened

16/j.mayocp.2014.01.001edical Education and Research

677

TABLE 1. Comparison of14 to 59 Years in 2005 to

Race/ethnicity

OverallNon-Hispanic whiteNon-Hispanic blackMexican American

aNote that data for 1999 to 20vention as whole numbers,2 wh

ARTICLE HIGHLIGHTS

n There has been a rise in circumcisions in men to 81% during thepast decade.

n The rise has occurred in white (91%), black (76%), and Hispanic(44%) males.

n Corrected hospital discharge data show a fall in national neonatalcircumcision prevalence of 6 percentage points to 77%.

n The fall in infant circumcisions is concomitant with demographicchanges, most notably the increase in the proportion of His-panic people (traditionally noncircumcising) in Western statesbut also the withdrawal of Medicaid coverage in 18 states.

n A risk-benefit analysis shows that benefits vastly exceed risks.

n Ethical and legal considerations support the right of male minors toprotection fromdiseasebyparents consenting to their circumcision.

n The affirmative policy of the American Academy of Pediatricsshould logically result in an increase in infant circumcisions inthe United States and in reintroduction of access to Medicaidfunding for poor families.

MAYO CLINIC PROCEEDINGS

678

in the 1950s through the 1990smay not be whatis happening today.

Estimates of prevalence of neonatal circum-cision generally rely on hospital discharge data.3

Such figures are taken from records of proce-dures performed during the neonatal hospitalstay. However, few studies have investigatedthe reliability of hospital discharge data as an es-timate of neonatal circumcision prevalence;those that have done so have found a substantialdiscrepancy. A survey in Maryland found thatthe prevalence was 75.3% based on hospitaldischarge data but 82.3% based on a post-partum survey.4 An earlier study in Atlantafound that circumcision was recorded for only

Total Circumcision Prevalence in Men and Boys Aged20101 Compared With 1999 to 20042a

Prevalence (% [95% CI])

Change (%)1999-2004 2005-2010

79 (77-80) 80.5 (78.4-82.5) þ2.588 (87-90) 90.8 (89.1-92.6) þ3.473 (69-77) 75.7 (72.0-79.4) þ4.142 (43-57) 44.0 (41.0-46.9) þ4.8

04 were published by the Centers for Disease Control and Pre-ereas data for 2005 to 2010 were published to 1 decimal point.1

Mayo Clin Proc. n May 2014

84.3% of boys who had received a circumci-sion.5 In referring to their sample in July 1985,the authors stated, “If we had relied solely on[summary information in the medical record,usually found on the face sheet] we wouldhave estimated that the circumcision rate forthat periodwas 75.3% rather than 89.3%.”5,p.414

These previous comparisons have been oflocal samples only. To better ascertain recenttrends nationally, we considered it instructiveto critically compare the new NHANES find-ings with National Hospital Discharge Survey(NHDS) data for 1979 to 2010 as reportedrecently by the CDC.3 The present evaluation,therefore, updates the comparison of NHANESand NHDS data by Waskett in 2007.6 Thatstudy was limited by having only 1980s birthsavailable for comparison. The present analysisis, therefore, more informative.

We show in Table 2 the prevalence ofcircumcision in the NHANES and NHDS sam-ples for comparable birth years. It is readilyapparent that NHANES data show a substan-tially higher prevalence of circumcision thansuggested by the NHDS figures. The recentNHDS analysis did note in the first paragraph,however, that their figures “do not include cir-cumcisions performed outside the hospitalsetting [...] or those performed at any agefollowing discharge from the birth hospitaliza-tion.”3 The present article refers to nonhospitaland postdischarge circumcisions as “unrecordedcircumcisions.” The number of these can be esti-mated by comparison of NHDS data withNHANES data, where the latter records circum-cisions performed at any time and any location.

Our calculation involved the following for-mula: a¼ iþ u(1e i), where a is the prevalencefrom NHANES data for men and boys aged 14to 59 years (which, for convenience, is referredto as “adult circumcisions” for the purpose ofthis article), i is the prevalence in infancy ascaptured by NHDS data, and u represents unre-corded circumcisions. Thus, u can be obtainedfrom values for a and i using simple algebra,ie, u ¼ (a e i) / (ei þ 1). An explanation ofthe rationale for this formula appears in theSupplemental Appendix (available online athttp://www.mayoclinicproceedings.org). Valuesfor these unrecorded circumcisions are shownin Table 2, alongside the percentage of malesdeemed by raw NHDS data to be uncircumcisedand the percentage who were actually found to

;89(5):677-686 n http://dx.doi.org/10.1016/j.mayocp.2014.01.001www.mayoclinicproceedings.org

TABLE 2. Comparison of NHANES1 and NHDS3

Circumcision Prevalence Data for ComparableBirth Years

Birth years

Prevalence (%)

NHANES NHDS Unrecorded

1970-1979 82.0 64.5 49.31980-1989 79.8 61.2 47.91990-1996 76.2 60.9 39.1

NHANES ¼ National Health and Nutrition ExaminationSurvey; NHDS ¼ National Hospital Discharge Survey.

TABLE 3. Projected Adult Prevalence ofCircumcision

Birth years

Prevalence (%)

NHDS Adult

1997-1999 62.5 79.52000-2009 58.0 77.12010 58.3 77.2

NHDS ¼ National Hospital Discharge Survey.

1950 1960 1970 1980 1990 2000 2010Birth year

Adu

lt ci

rcum

cisi

on p

reva

lenc

e, %

100

80

60

40

20

0

FIGURE. Prevalence of adult circumcision in the United States during thepast 6 decades (1948-2010).1,2,7,8 The solid line represents documentedprevalence among adults; dashed line, our predictions (see the text for howthis was derived).

CIRCUMCISION TRENDS IN THE UNITED STATES

be circumcised according to the NHANESs ofadults and older boys.

The percentage of unrecorded circumci-sions is similar across the 3 groups of birthyears. The figure is somewhat smaller for themost recent birth years (1990-1996). Thisfinding may be the result of a random fluctua-tion or a downward trend, or it may reflect thefact that this cohort includes males as young as14 years, who have had less time in which to becircumcised, although circumcision later inchildhood is much less common than duringthe neonatal period. Using data from the localstudies in Maryland4 and Atlanta5 discussedpreviously herein, we calculate that unrecordedcircumcisions in these studies were 28.3% and56.7%, respectively, ie, they were comparablewith those in Table 2 for national data.

We found the mean percentage of unre-corded circumcisions in Table 2 to be 45.4%.On the basis of this figure, we provide inTable 3 predictions for the prevalence of adultcircumcision in males born between 1997 and2010. Although we found that there has beena decline in the prevalence of circumcisionfrom the peak of 83.3% in 1960 to 1969,1 thedecline is comparatively small, having fallenonly 6.1 percentage points from the 1960 to1969 birth cohort to the 2010 birth cohort (ie,83.3 e 77.2 ¼ 6.1).

Based on the information previously here-in, we show in the Figure the overall preva-lence of circumcision in the United Statesfrom the late 1940s to 2010.

Earlier NHDS data to the year 2000 foundan increase in neonatal circumcision from48.3% of newborns in 1988 to 1991 to61.1% in 1997 to 2000 (P<.0001).9 Theserates came from a study of 4,657,402 newbornmale hospitalizations from the Nationwide

Mayo Clin Proc. n May 2014;89(5):677-686 n http://dx.doi.org/10.10www.mayoclinicproceedings.org

Inpatient Sample that identified newbornswho underwent circumcision during a 13-year period using International Classificationof Diseases, Ninth Revision procedure codes. A2011 CDC report based on NHDS statisticsfound, however, a decrease from 62.5% in1999 to 56.9% in 2008.10

Thus, despite the 2013 CDC report based onNHANES data for 2005 to 2010 having shownthat circumcision prevalence has risen margin-ally in all racial groups, the present analysis re-veals a 6 percentage point fall in the overallprevalence of newborn circumcision in recenttimes. The main reason is most likely the muchfaster increase in the Hispanic population,11 the

16/j.mayocp.2014.01.001 679

TABLE 4. Comprehensive

Conditio

Risks of not circumcisingc

Urinary tract infection: agUrinary tract infection: agUrinary tract infection: agUrinary tract infection: lifePyelonephritis (infants)

With concurrent bacte

Hypertension in earlyEnd-stage renal disease

CandidiasisProstate cancer

MAYO CLINIC PROCEEDINGS

680

ethnic group having the lowest circumcisionprevalence. The burgeoningHispanic populationin the West accounts for most of the decrease innational prevalence.3 Because Hispanic andblack individuals are overrepresented in poorerdemographics, the withdrawal of Medicaid fund-ing for elective circumcision in 18 states is ofconcern to public health,12,13 as was alsoexpressed by the authors of the CDC’s recentreport.1 After controlling for other factors, stateswith Medicaid coverage had hospital circumci-sion rates 24 percentage points higher than stateswithout such coverage.12

PEDIATRIC RECOMMENDATIONCircumcision ratesmay have been influenced, inpart, by the periodic reports from the AmericanAcademy of Pediatrics (AAP). These reports havechanged slowly from negative in the 1970s toneutral in 1999 to positive in 2012.14 It will beinteresting to see what impact the recent changein recommendations by the AAP will have onnational circumcision rates. The AAP reportfound (1) that the benefits of infantmale circum-cision exceed the risks; (2) that parents are enti-tled to factually correct, nonbiased informationabout benefits and risks; (3) that access tocircumcision should be provided for familieswho choose it; (4) that effective pain manage-ment and sterile technique should be used;and (5) that third-party reimbursement is war-ranted. The AAP’s policy was developed by eth-icists, epidemiologists, and clinical experts,

Risk-Benefit Analysis of Infant Male Circumcisiona

nFold increase inrisk (95% CI)

Rating ofevidenceb

Percentageaffected

e 0-1 y 9.9 (7.5-13) 1þþ 1.3d Me l-16 y 6.6 (3.3-13) 1þþ 2.7d Me >16 y 3.4 (0.92-50) 1þ 28d Mtime 3.6 (1.8-5.7) 1þ 32d M

10 2þ 0.6d Zo

remia 20 2þ 0.1d Zo

adulthood e 2e 0.1d Jacin early adult e 2e 0.06d Jac

2.5 (1.7-3.7) 2þ 10d Ric1.2-2 2þ 2-10d W

Mayo Clin Proc. n May 2014

assisted by the CDC, the American Academy ofFamily Physicians, and the American College ofObstetrics and Gynecology. The AAP policygraded the quality of the research that the TaskForce cited and concluded, “Evaluation of cur-rent evidence indicates that the health benefitsof newborn male circumcision outweigh therisks, and the benefits of newborn male circum-cision justify access to this procedure for thosefamilies who choose it.”14,p.e756,e757,e778 It isnot prescriptive. Instead, it states, “Parentsshould weigh the health benefits and risks inlight of their own religious, cultural, andpersonalpreferences, as the medical benefits alone maynot outweigh these other considerations for indi-vidual families.” Thus, it retains the balance ofrights and responsibilities between the individualchild, the child’s parents, and society at large. TheAAP’s 2012 reportmight be regarded as close to arecommendation asmight be possible in the pre-sent era of autonomy, where even vaccinationscan be refused by parents for their children.

RISK-BENEFITThe AAP Task Force did not conduct a risk-benefit analysis. Because it considered theliterature only to 2010, it did not capturerisk-benefit analyses published in 2012.15,16

Table 4 provides an updated risk-benefit anal-ysis drawing on literature cited in the latterstudies and in the AAP report14 and on datain more recent reviews and meta-analyses.This analysis shows that over the lifetime,

Reference, year

orris and Wiswell,17 2013orris and Wiswell,17 2013orris and Wiswell,17 2013orris and Wiswell,17 2013rc et al,18 2005; Rushton and Majd,19 1992; Rushton,20

1997; Elder,21 2007rc et al,18 2005; Rushton and Majd,19 1992; Rushton,20

1997; Elder,21 2007obson et al,22 1989obson et al,22 1989hters et al,23 2006right et al,24 2012; Morris et al,25 2007; Morris et al,26

2011; Morris and Waskett,27 2012

Continued on next page

;89(5):677-686 n http://dx.doi.org/10.1016/j.mayocp.2014.01.001www.mayoclinicproceedings.org

TABLE 4. Continued

ConditionFold increase inrisk (95% CI)

Rating ofevidenceb

Percentageaffected Reference, year

Risks of not circumcisingc, continuedBalanitis 3.1 (1.9-5.0) 1þ 10d Morris et al,16 2012Phimosis 100 1þþ 10d Morris,28 2007High-risk HPV infection 1.5 (1.1-2.0) 1þþ 6d Tobian et al,29 2009; Auvert et al,30 2009

2.7 (1.2-6.3) 1þ 10d Morris et al,26 2012; Castellsagué et al,31 2002; Miralles-Guriet al,32 2009; Albero et al,33 2012

Herpes simplex virus type 2 1.4 (1.0-2.5) 1þþ 4d Tobian et al,29 2009; Sobngwi-Tambekou et al,34 2009;Tobian et al,35 2009

1.1 (1.0-1.3) 1e 1d Weiss et al,36 2006Genital ulcer disease 2.0 (1.4-2.3) 1þ 2d Gray et al,37 2009Trichomonas vaginalis 1.9 (1.0-3.6) 1þ 0.5d Sobngwi-Tambekou et al,38 2009Mycoplasma genitalium 1.8 (1.0-3.4) 1þþ 1d Mehta et al,39 2012Chancroid 0.1-1.1 1þþ Lowd Weiss et al,36 2006Syphilis 1.9 (1.2-2.9) 2þ Lowd Weiss et al,36 2006HIV (acquired heterosexually) 2.4 (1.8-3.2) 1þþ 0.3d Siegfried et al,40 2009; Weiss et al,41 2008; Sansom et al,42

2010; Morris et al,43 2012Penile cancer (lifetime) >20 1þþ 0.1d American Academy of Pediatrics,14 2012; Morris et al,26

2011In female partnerCervical cancer 2.4 (1.3-4.3) 2þþ NA Castellsagué et al,31 2002; Bosch et al,44 2009Chlamydia trachomatis 5.6 (1.7-20) 2þ NA Castellsagué et al,45 2005Herpes simplex virus type 2 2.2 (1.4-3.6) 2þ NA Cherpes et al,46 2003Trichomonas vaginalis 1.9 (1.0-10) 1þþ NA Gray et al,47 2009Bacterial vaginosis 1.7 (1.1-2.6) 1þþ NA Gray et al,47 2009

Risks associated with neonatal circumcisione

Local bruising at the site of injection of localanesthetic (if dorsal penile nerve blockused)

NA NA 25f NA

Infection, local NA NA 0.2f NAInfection, systemic NA NA 0.02f NAExcessive bleeding NA NA 0.1f NANeed for repeat surgery (if skin bridges or toolittle prepuce is removed)

NA NA 0.1f NA

Loss of penis NA NA 0.0001f NADeath NA NA 0.00001f NALoss of penile sensitivity NA NA 0f NA

aHIV ¼ human immunodeficiency virus; HPV ¼ human papillomavirus; NA ¼ not applicable.bRating of evidence was based on the Scottish Intercollegiate Guidelines Network grading system for evidence-based guidelines48: high-quality meta-analyses, systematicreviews of randomized controlled trials (RCTs), or RCTs with very low risk of bias (1þþ); well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with low riskof bias (1þ); meta-analyses, systematic reviews of RCTs, or RCTs with high risk of bias (1e); high-quality systematic reviews of case-control or cohort studies or high-qualitycase-control or cohort studies with a very low risk of confounding, bias, or chance and a high probability that the relationship is causal (2þþ); well-conducted case-controlor cohort studies with a low risk of confounding, bias, or chance and a moderate probability that the relationship is causal (2þ); and case-control or cohort studies with ahigh risk of confounding, bias, or chance and a significant risk that the relationship is not causal (2e); reports with lower ratings, such as case reports and case series (3) andexpert opinion (4), were not considered.cThese data show that the risk to an uncircumcised male of developing a condition requiring medical attention during their lifetime is approximately 1 in 2. Values shown aremostly based on statistics for the United States unless RCT data were available from other countries. State-of-the-art reviews are shown where possible rather than in-dividual studies. Information on sexually transmitted infections applies to those acquired in heterosexual males.dThe percentage of uncircumcised affected is the inverse of the number needed to treat value, which is the approximate number of males who need to be circumcised toprevent 1 case of each condition associated with lack of circumcision.eThese data show that risk of an easily treatable condition is approximately 1 in 200 and of a serious complication is 1 in 5000. Estimates are taken from American Academyof Pediatrics,14 2012; Wiswell and Geschke,49 1989; and Ben Chaim et al,50 2005.fPercentage affected is the inverse of the number needed to harm value, which is the approximate number of males who need to be circumcised to see one of eachparticular (mostly minor) adverse effect. The item “local bruising” is not included in the overall calculation of easily treatable risks because this phenomenon disappearsnaturally without any medical intervention.

CIRCUMCISION TRENDS IN THE UNITED STATES

Mayo Clin Proc. n May 2014;89(5):677-686 n http://dx.doi.org/10.1016/j.mayocp.2014.01.001www.mayoclinicproceedings.org

681

MAYO CLINIC PROCEEDINGS

682

benefits exceed risks by at least 100 to 1. Ifone considers the seriousness of some condi-tions that circumcision protects against, thebenefit would actually be much greater. Basedon risk-benefit considerations, neonatal cir-cumcision might rationally be considered inthe same light as childhood vaccination.

ACCESS AND FUNDINGIn most states, Medicaid covers infant malecircumcision for the poor. The CDC reportcriticized the lack of Medicaid coverage forelective circumcision in 18 states.1 The CDCauthors estimated that there were 3.5 millionuncircumcised men and boys potentially atrisk for heterosexually acquired human immu-nodeficiency virus (HIV), 48.3% of whomlacked health insurance. It is the poor withinminorities, principally black and Hispanic,who present the highest disease burden fromlack of circumcision. With this and privatehealth insurance coverage in mind, the AAPguidelines state that the preventive and publichealth benefits associated with newborn malecircumcision warrant third-party reimburse-ment of the procedure.14 Their statement rein-forces calls for a reevaluation by these 18 statesof parental access to and funding for electivecircumcision, which has been regarded as a“health parity right of the poor.”12,13,51

COST-BENEFITA cost-effectiveness study that considered onlyinfant urinary tract infections and sexuallytransmitted infections (STIs) found that ifmale circumcision rates were to decrease tothe levels of 10% typically seen in Europe, theadditional direct medical costs in infancy andlater for treatment of these among 10 annualbirth cohorts would exceed $4.4 billion, evenafter accounting for the cost of the procedure(average, $291; range, $146-$437) and treat-ment of complications (average cost, $185each [range, $130-$235]; prevalence, 0.4%[range, 0.2%-0.6%]).52 Each forgone infantcircumcision procedure was estimated to leadto an average of $407 in increased direct med-ical expenses per male and $43 per female.52

This analysis did not consider other conditions,and neither did it consider the indirect costs. Itseems logical then that this analysis might havegreatly underestimated the true cost. The studyadds to one by the CDC that found that

Mayo Clin Proc. n May 2014

neonatal male circumcision was cost-savingfor HIV prevention, at least in black and His-panic males, in whom HIV prevalence is high-est.42 An Australian analysis of genital cancerprevention found that neonatal circumcisionprovides at least partial cost savings for these.53

A study of a Medicaid birth cohort of29,316 found that for every year of decreasedcircumcision due to Medicaid defunding therewould be more than 100 additional HIV casesand $30 million in net medical costs as a resultof these.54 The cost to circumcise males in thisbirth cohort was $4,856,000. Modeling hasfound that cost savings initially generated bynoncoverage of elective circumcisions byMedicaid in Louisiana55 and Florida56 wasmitigated by increases in the rate and expenseof medically indicated circumcisions. The Lou-isiana study considered only the costs of thesefor boys aged 0 to 5 years. Lifetime costs wouldrepresent a much greater financial impact onhealth care systems. The Florida study involvedmales aged 1 to 17 years undergoing circumci-sion between 2003 and 2008 and found thatMedicaid defunding was followed by a 6-foldrise in publicly funded circumcisions (cost ¼$111.8 million).56

ETHICAL AND LEGAL ISSUESParents can legally authorize surgical proce-dures in the best interests of their chil-dren.14,57-60 The AAP’s ethics committee andothers support this contention,61,62 as doesArticle 14(2) of the United Nations Conven-tion on the Rights of the Child (UNCRC) 44/25 of November 20, 1989.63 Exceptionsinclude failing to act in the interests of chil-dren and situations in which a medical proce-dure or withholding a medical proceduremight cause serious harm. Because infantmale circumcision is not prejudicial to thehealth of children but instead is beneficial, italso does not violate Article 24(3) of theUNCRC. This document does not refer tochildhood male circumcision. If it did, thenit is unlikely that the UNCRC would have assignatories almost all the Islamic states andIsrael.64 Article 24(1) of the UNCRC calls onparties to agree to “recognize the right of thechild to the enjoyment of the highest attain-able standard of health and to facilities forthe treatment of illness and rehabilitation ofhealth. States Parties shall strive to ensure

;89(5):677-686 n http://dx.doi.org/10.1016/j.mayocp.2014.01.001www.mayoclinicproceedings.org

CIRCUMCISION TRENDS IN THE UNITED STATES

that no child is deprived of his or her right ofaccess to such health care services.”63

Although some argue that a child has a rightto “bodily integrity” and, thus, that circumcisionof boys should be banned, discouraged, or atleast delayed until he can decide for himself,65-67

others disagree64,68-71 based on several reasons,some of which are discussed later herein. Oneauthor argues that being circumcised boosts au-tonomy more than constraining it.72 Article24(3) of the UNCRC seeks to abolish traditionalpractices prejudicial to the health of children.63

Because infant male circumcision is not prejudi-cial to the health of children but rather is bene-ficial, it does not violate Article 24(3).64 In fact,one commentator construed Article 24(3) asrequiring circumcision.64 He pointed out thatthe tradition in countries that abstain fromcircumcision can, in fact, be judged as beingprejudicial to the health of children.64 He usedas an example the increased risk in sexuallyactive minors of acquisition and transmissionof potentially fatal oncogenic human papilloma-virus genotypes and HIV.

Most parents care deeply for their childrenand try to dowhat is best for them. The AAP rec-ommended development of unbiased educa-tional material and that physicians routinelydiscuss the circumcision decision with parentsearly in a pregnancy. Fully informed parentsmight likely choose to have their baby boycircumcised.73 It has been argued that parentswho are opposeddeven after being fully infor-meddwould seem to place greater value on pre-serving the foreskin than in protecting theirchild against the harms, to the boy and his futuresexual partners, of the uncircumcised state.64

Nevertheless, some parents may refrain out ofrespect for cultural traditions or perhaps reli-gion; others out of a philosophical position ofopposing anything other than the natural stateor the acceptance of the alternative views of op-ponents. Regardless, the decision of parents whorefuse should be respected and accepted.

Arguments by opponents start with thepremise that circumcision of males has no bene-fits, only harms, or that the benefits only applylater in life when the male can make the circum-cision decision for himself.66,74 Table 4 showsthat benefits apply in the early pediatric periodand extend all the way through life to the geriatricperiod. Problems in uncircumcised elderly men,especially in nursing homes, are underrecognized

Mayo Clin Proc. n May 2014;89(5):677-686 n http://dx.doi.org/10.10www.mayoclinicproceedings.org

and need more attention and research. Anotherclaim is that circumcision diminishes sexualfunction, sensitivity, and pleasure.67,74,75 Arecent exhaustive systematic literature review76

and a meta-analysis77 found either no adverse ef-fect or an improvement in these parameters as aresult of circumcision.

Parents and physicians each have an ethicalduty to the child to attempt to secure the child’sbest interest and well-being.78 Because the ben-efits outweigh the risks and the procedure issafe (Table 4), circumcision might be seen inthe same light as other interventions that par-ents must choose for their child. It is the dutyof states to create conditions necessary for thefulfillment of rights to good health by facili-tating the availability of interventions that arebeneficial. Logically it can be argued thatshould include male circumcision.79 Ethically,infant male circumcision seems to fall withinthe prerogative of parental decision making.71

A landmark review a decade ago noted thatmost decisions made by parents for their chil-dren will likely have a more profound effecton them than the presence or absence of aforeskin.80

The timing of circumcision is crucial. Med-ical and practical considerations strongly favorthe neonatal period (Table 4).16 Surgical riskis, thereby, minimized and the accumulatedhealth benefits are maximized.14,16 If circum-cision is not performed, one of the benefitspotentially lost is protection against urinarytract infections that in infancy may lead to kid-ney damage (see the recent review by Morrisand Wiswell17). Those who argue that circum-cision can be delayed so that the boy can makeup his own mind when older might not haveconsidered that the operation on mature geni-talia is not as simple as the surgery on a babyboy’s penis. Delay may result in increased cost,a higher risk of complications, anesthesia riskif a general anesthetic is used (as is morelikely), a longer healing time, a poorercosmetic outcome should sutures be used, arequirement for temporary sexual abstinence,interference with education or employment,and loss of opportunity for, or delay in, theachievement of protection from STIs for thosewho become sexually active early and for thosewho ignore advice on abstinence, therebyexposing them to increased risk of STIs duringthe 6-week healing period.14,16 Thus, it is

16/j.mayocp.2014.01.001 683

MAYO CLINIC PROCEEDINGS

684

disingenuous to suggest that the procedure iscomparable at both ages.64 Furthermore, anadult cannot consent to his own infantcircumcision.64

Many nations that condemn childhoodmalecircumcision are not as quick to condemn othercomparably invasive and dangerous proceduresthat have no medical benefit,64 eg, cosmeticorthodontia, correction of harelip, surgery fortongue-tie, growth hormone injections for treat-ment of dwarfism, and removal of supernumer-ary digits.64 Thus, as stated by Jacobs,64 it seemsodd that neonatal male circumcision is regardedby some as controversial.

As far as the law is concerned, there is aview that the legal system has no place inter-fering in medical practice when it is basedon evidence except to ensure that profes-sionals always act responsibly.

CONCLUSIONThe latest data on male circumcision in theUnited States show a 2.5% overall increasein prevalence in males aged 14 to 59 years be-tween 2000 and 2010. In contrast, there hasbeen a downward trend in neonatal circumci-sions, with the present analyses finding thatthe true extent of this decline is 6 percentagepoints. Given (1) the wide-ranging protectionthat neonatal circumcision affords against a di-versity of medical conditions, some of whichcan be fatal; (2) the high benefit to risk ratio;(3) the data on cost-effectiveness; and (4) theaffirmative AAP policy in 2012, in our view,it might be an appropriate time for govern-ments, insurers, and the medical professionto act. When considered together with ethicaland human rights arguments, neonatal cir-cumcision should logically be strongly sup-ported and encouraged as an importantevidence-based intervention akin to childhoodvaccination. We predict that states thatcurrently no longer cover elective circumcisionunder Medicaid will restore provision of thisprocedure for those unable to afford it, espe-cially because it will lead to considerableshort- and long-term savings to governmenthealth budgets by reducing more expensivecircumcisions for medical need later, wherethese often involve costly general anesthesia;it will also reduce the cost of treatment ofthe many foreskin-mediated conditions, infec-tions, and cancers in males and their sexual

Mayo Clin Proc. n May 2014

partners that male circumcision affords vary-ing degrees of protection against. We predictthat future CDC surveys will find significantongoing increases in the prevalence of circum-cision in the United States.

SUPPLEMENTAL ONLINE MATERIALSupplemental material can be found online athttp://www.mayoclinicproceedings.org.

Abbreviations and Acronyms: AAP = American Academyof Pediatrics; CDC = Centers for Disease Control and Pre-vention; HIV = human immunodeficiency virus; NHANES =National Health and Nutrition Examination Surveys; NHDS =National Hospital Discharge Survey; STI = sexually trans-mitted infection; UNCRC = United Nations Convention onthe Rights of the Child

Correspondence: Address to Brian J. Morris, DSc, PhD,School of Medical Sciences, Building F13, University of Sydney,Sydney, NSW 2006 Australia (brian.morris@sydney.edu.au).

REFERENCES1. Introcaso CE, Xu F, Kilmarx PH, et al. Prevalence of circumci-

sion among men and boys aged 14 to 59 years in the UnitedStates, national health and nutrition examination surveys2005-2010. Sex Transm Dis. 2013;40(7):521-525.

2. Xu F, Markowitz LE, Sternberg MR, Aral SO. Prevalence ofcircumcision and herpes simplex virus type 2 infection inmen in the United States: the National Health and NutritionExamination Survey (NHANES), 1999-2004. Sex Transm Dis.2007;34(7):479-484.

3. Owings M, Uddin S, Williams S. Trends in circumcision for malenewborns in U.S. hospitals: 1979-2010. National Center forHealth Statistics website. http://www.cdc.gov/nchs/data/hestat/circumcision_2013/circumcision_2013.pdf. Accessed September5, 2013.

4. Cheng D, Hurt L, Horon IL. Neonatal circumcision in Maryland:a comparison of hospital discharge and maternal postpartumsurvey data. J Pediatr Urol. 2008;4(6):448-451.

5. O’Brien TR, Calle EE, Poole WK. Incidence of neonatal circumci-sion in Atlanta, 1985-1986. Southern Med J. 1995;88(4):411-415.

6. Waskett JH. Hospital discharge data underestimate circumci-sion rates. Sex Transm Dis. 2007;34:624.

7. Slaby AR, Drizd T. Circumcision in the United States. Am J Pub-lic Health. 1985;75(8):878-880.

8. Laumann EO, Maal CM, Zuckerman EW. Circumcision in theUnited States: prevalence, prophyactic effects, and sexual prac-tice. JAMA. 1997;277(13):1052-1057.

9. Nelson CP, Dunn R, Wan J, Wei JT. The increasing incidence ofnewborn circumcision: data from the nationwide inpatient sam-ple. J Urol. 2005;173:978-981.

10. Centers for Disease Control and Prevention. Trends in in-hospital newborn male circumcisiondUnited States, 1999-2010. MMWR Morb Mortal Wkly Rep. 2011;60(34):1167-1168:http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6034a4.htm.Accessed December 29, 2013.

11. Campbell PR. Population projections for states by age, sex,race, and Hispanic origin: 1995 to 2025. PPL-47. http://www.census.gov/population/projections/files/methodology/ppl47.pdf.Published 1996. Accessed December 29, 2013.

12. Leibowitz AA, Desmond K, Belin T. Determinants and policyimplications of male circumcision in the United States. Am JPublic Health. 2009;99(1):138-145.

;89(5):677-686 n http://dx.doi.org/10.1016/j.mayocp.2014.01.001www.mayoclinicproceedings.org

CIRCUMCISION TRENDS IN THE UNITED STATES

13. Morris BJ, Bailis SA, Waskett JH, et al. Medicaid coverage ofnewborn circumcision: a health parity right of the poor. Am JPublic Health. 2009;99(6):969-971.

14. American Academy of Pediatrics Task Force on Circumcision.Circumcision policy statement. Pediatrics. 2012;130(3):e756-e785.

15. Morris BJ, Wodak AD, Mindel A, et al. Infant male circumcision:an evidence-based policy statement. Open J Prevent Med. 2012;2(1):79-82.

16. Morris BJ, Waskett JH, Banerjee J, et al. A “snip” in time: what isthe best age to circumcise? BMC Pediatr. 2012;12:20.

17. Morris BJ, Wiswell TE. Circumcision and lifetime risk of urinarytract infections: a systematic review and meta-analysis. J Urol.2013;189(6):2118-2124.

18. Zorc JJ, Kiddoo DA, Shaw KN. Diagnosis and management ofpediatric urinary tract infections. Clin Microbiol Rev. 2005;18(2):417-422.

19. Rushton HG, Majd M. Dimercaptosuccinic acid renal scintig-raphy for the evaluation of pyelonephritis and scarring: a reviewof experimental and clinical studies. J Urol. 1992;148(5, pt 2):1726-1732.

20. Rushton HG. Urinary tract infections in children: epidemiology,evaluation, and management. Pediatr Clin North Am. 1997;44(5):1133-1169.

21. Elder JS. Urinary tract infections. In: Kligeman RM, Behrman RE,Jenson HB, Stanton BF, eds. Textbook of Pediatrics. 18th ed. Phil-adelphia, PA: Saunders Elsevier; 2007:2223-2228.

22. Jacobson SH, Eklof O, Eriksson CG, et al. Development of hy-pertension and uraemia after pyelonephritis in childhood: 27year follow up. BMJ. 1989;299(6701):703-706.

23. Richters J, Smith AM, de Visser RO, et al. Circumcision inAustralia: prevalence and effects on sexual health. Int J STDAIDS. 2006;17(8):547-554.

24. Wright JL, Lin DW, Stanford JL. Circumcision and the risk ofprostate cancer. Cancer. 2012;118(18):4437-4443.

25. Morris BJ, Waskett J, Bailis SA. Case number and the financialimpact of circumcision in reducing prostate cancer. BJU Int.2007;100(1):5-6.

26. Morris BJ, Gray RH, Castellsague X, et al. The strong protectionafforded by circumcision against cancer of the penis. Adv Urol.2011;2011:812368.

27. Morris BJ, Waskett JH. Circumcision reduces prostate cancerrisk. Asian Pacific J Androl. 2012;14(5):661-662.

28. Morris BJ. Why circumcision is a biomedical imperative for the21st century. BioEssays. 2007;29(11):1147-1158.

29. Tobian AAR, Serwadda D, Quinn TC, et al. Male circumcisionfor the prevention of HSV-2 and HPV infections and syphilis.N Engl J Med. 2009;360(13):1298-1309.

30. Auvert B, Sobngwi-Tambekou J, Cutler E, et al. Effect of malecircumcision on the prevalence of high-risk human papilloma-virus in young men: results of a randomized controlled trialconducted in Orange Farm, South Africa. J Infect Dis. 2009;199(1):14-19.

31. Castellsagué X, Bosch FX, Munoz N, et al. Male circumcision,penile human papillomavirus infection, and cervical cancer in fe-male partners. N Engl J Med. 2002;346(15):1105-1112.

32. Miralles-Guri C, Bruni L, Cubilla AL, et al. Human papillomavirusprevalence and type distribution in penile carcinoma. J ClinPathol. 2009;62(10):870-878.

33. Albero G, Castellsagué X, Giuliano AR, Bosch FX. Male circum-cision and genital human papillomavirus: a systematic reviewand meta-analysis. Sex Transm Dis. 2012;39(2):104-113.

34. Sobngwi-Tambekou J, Taljaard D, Lissouba P, et al. Effect ofHSV-2 serostatus on acquisition of HIV by young men: resultsof a longitudinal study in Orange Farm, South Africa. J Infect Dis.2009;199(7):958-964.

35. Tobian AAR, Charvat B, Ssempijja V, et al. Factors associatedwith the prevalence and incidence of herpes simplex virustype 2 infection among men in Rakai, Uganda. J Infect Dis.2009;199(7):945-949.

Mayo Clin Proc. n May 2014;89(5):677-686 n http://dx.doi.org/10.10www.mayoclinicproceedings.org

36. Weiss HA, Thomas SL, Munabi SK, Hayes RJ. Male circumci-sion and risk of syphilis, chancroid, and genital herpes: a sys-tematic review and meta-analysis. Sex Transm Infect. 2006;82(2):101-109.

37. Gray RH, Serwadda D, Tobian AAR, et al. Effects of genital ul-cer disease and herpes simplex virus type 2 on the efficacy ofmale circumcision for HIV prevention: analyses from the Rakaitrials. PLoS Med. 2009;6(11):e1000187.

38. Sobngwi-Tambekou J, Taljaard D, Nieuwoudt M, et al. Malecircumcision and Neisseria gonorrhoeae, Chlamydia trachomatis,and Trichomonas vaginalis: observations in the aftermath of arandomised controlled trial for HIV prevention. Sex TransmInfect. 2009;85(2):116-120.

39. Mehta SD, Gaydos C, Maclean I, et al. The effect of medicalmale circumcision on urogenital Mycoplasma genitalium amongmen in Kisumu, Kenya. Sex Transm Dis. 2012;39(4):276-280.

40. Siegfried N, Muller M, Deeks JJ, Volmink J. Male circumcision forprevention of heterosexual acquisition of HIV in men. CochraneDatabase Syst Rev. 2009;(2):CD003362. http://dx.doi.org/10.1002/14651858.CD003362.pub2.

41. Weiss HA, Halperin D, Bailey RC, et al. Male circumcision forHIV prevention: from evidence to action [review]? AIDS.2008;22(5):567-574.

42. Sansom SL, Prabhu VS, Hutchinson AB, et al. Cost-effectivenessof newborn circumcision in reducing lifetime HIV risk among U.S. males. PLoS One. 2010;5(1):e8723.

43. Morris BJ, Bailey RC, Klausner JD, et al. Review: a critical eval-uation of arguments opposing male circumcision for HIVprevention in developed countries. AIDS Care. 2012;24(12):1565-1575.

44. Bosch FX, Albero G, Castellsagué X. Male circumcision, humanpapillomavirus and cervical cancer: from evidence to interven-tion. J Fam Plann Reprod Health Care. 2009;35(1):5-7.

45. Castellsagué X, Peeling RW, Franceschi S, et al. Chlamydia tra-chomatis infection in female partners of circumcised and uncir-cumcised adult men. Am J Epidemiol. 2005;162(9):907-916.

46. Cherpes TL, Meyne LA, Krohn MA, Hiller SL. Risk factors forinfection with herpes simplex virus type 2: role of smoking,douching, uncircumcised males, and vaginal flora. Sex TransmDis. 2003;30(5):405-410.

47. Gray RH, Kigozi G, Serwadda D, et al. The effects of malecircumcision on female partners’ genital tract symptoms andvaginal infections in a randomized trial in Rakai, Uganda. Am JObstet Gynecol. 2009;200(1):e1-e7.

48. Harbour R, Miller J. A new system for grading recommendationsin evidence based guidelines. BMJ. 2001;323(7308):334-336.

49. Wiswell TE, Geschke DW. Risks from circumcision during thefirst month of life compared with those for uncircumcised boys.Pediatrics. 1989;83(6):1011-1015.

50. Ben Chaim J, Livne PM, Binyamini J, et al. Complications ofcircumcision in Israel: a one year multicenter survey. Isr MedAssoc J. 2005;7(6):368-370.

51. Tobian AA, Gray RH. The medical benefits of male circumci-sion. JAMA. 2011;306(13):1479-1480.

52. Kacker S, Frick KD, Gaydos CA, Tobian AA. Costs and effec-tiveness of neonatal male circumcision. Arch Pediatr AdolescMed. 2012;166(10):910-918.

53. Morris BJ, Mindel A, Tobian AAR, et al. Should male circumci-sion be advocated for genital cancer prevention? Asian Pacific JCancer Prevent. 2012;13(9):4839-4842.

54. Andrews AL, Lazenby GB, Unal ER, Simpson KN. The cost ofmedicaid savings: the potential detrimental public health impactof neonatal circumcision defunding. Infect Dis Obstet Gynecol.2012;2012:540295.

55. Ortenberg J, Roth CC. Projected financial impact of noncov-erage of elective circumcision by Louisiana Medicaid in boys0-5 years old. J Urol. 2013;190(4 suppl):1540-1544.

56. Gutwein LG, Alvarez JF, Gutwein JL, et al. Allocation of health-care dollars: analysis of nonneonatal circumcisions in Florida.Am Surg. 2013;79(9):865-869.

16/j.mayocp.2014.01.001 685

MAYO CLINIC PROCEEDINGS

686

57. Viens AM. Value judgement, harm, and religious liberty. J MedEthics. 2004;30(3):241-247.

58. Etchells E, Sharpe G, Walsh P. Consent for circumcision. CanMed Assoc J. 1997;156(1):18.

59. Morris BJ, Tobian AA. Legal threat to infant male circumcision.JAMA Pediatr. 2013;167(10):890-891.

60. Bates MJ, Ziegler JB, Kennedy SE, et al. Recommendation by alaw body to ban infant male circumcision has serious world-wide implications for pediatric practice and human rights.BMC Pediatr. 2013;13:136.

61. American Academy of Pediatrics Committee on Bioethics.Informed consent, parental permission, and assent in pediatricpractice. Pediatrics. 1995;95(2):314-317.

62. Diekema DS. Parental refusals of medical treatment: the harmprinciple as threshold for state intervention. Theor Med Bioeth.2004;25(4):243-264.

63. United Nations Convention on the Rights of the Child 44/25.http://www.un.org/documents/ga/res/44/a44r025.htm. PublishedNovember 20, 1989. Accessed November 19, 2013.

64. Jacobs AJ. The ethics of circumcision of male infants. Isr MedAssoc J. 2013;15(1):60-65.

65. Merkel R, Putzke H. After Cologne: male circumcision and thelaw: parental right, religious liberty or criminal assault? J MedEthics. 2013;39(7):444-449.

66. Svoboda JS. Circumcision of male infants as a human rightsviolation. J Med Ethics. 2013;39(7):469-474.

67. Van Howe RS. Infant circumcision: the last stand for the deaddogma of parental (sovereignal) rights. J Med Ethics. 2013;39(7):475-481.

68. Benatar D, Benatar M. How not to argue about circumcision.Am J Bioethics. 2003;3(2):W1-W9.

Mayo Clin Proc. n May 2014

69. Clark PA, Eisenman J, Szapor S. Mandatory neonatal malecircumcision in Sub-Saharan Africa: medical and ethical analysis.Med Sci Monit. 2007;13(12):RA205-RA213.

70. Benatar D. Evaluations of circumcision should be circumscribedby the evidence. J Med Ethics. 2013;39(7):431-432.

71. Mazor J. The child’s interests and the case for the permissibilityof male infant circumcision. J Med Ethics. 2013;39(7):421-428.

72. Brusa M, Barilan YM. Cultural circumcision in EU public hospi-tals: an ethical discussion. Bioethics. 2009;23(8):470-482.

73. Adler R, Ottaway S, Gould S. Circumcision: we have heardfrom the experts; now let’s hear from the parents. Pediatrics.2001;107(2):E20.

74. Darby RJL. The child’s right to an open future: is the principleapplicable to non-therapeutic circumcision? J Med Ethics.2013;39(7):463-468.

75. Lang DP. Circumcision, sexual dysfunction and the child’s bestinterests: why the anatomical details matter. J Med Ethics. 2013;39(7):429-431.

76. Morris BJ, Krieger JN. Does male circumcision affect sexualfunction, sensitivity or satisfaction?ea systematic review. J SexMed. 2013;10(11):2644-2657.

77. Tian Y, Liu W, Wang JZ, et al. Effects of circumcision on malesexual functions: a systematic review and meta-analysis. Asian JAndrol. 2013;15(5):662-666.

78. Fleischman AR, Nolan K, Dubler NN, et al. Caring for gravely illchildren. Pediatrics. 1994;94(4, pt 1):433-439.

79. Stemple L. Health and human rights in today’s fight against HIV/AIDS. AIDS. 2008;22(suppl 2):S113-S121.

80. Alanis MC, Lucidi RS. Neonatal circumcision: a review of theworld’s oldest and most controversial operation. Obstet GynecolSurv. 2004;59(5):379-395.

;89(5):677-686 n http://dx.doi.org/10.1016/j.mayocp.2014.01.001www.mayoclinicproceedings.org